perspectives on heterogeneity in health care€¦ · myeloid leukemia. the effort, the...

Perspectives on Heterogeneity in Health Care Lewis G. Sandy MD FACP

―The Myth of Average: Why Individual Differences Matter‖

November 30, 2012

© 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited.


A Snapshot of the US Health Care System: July 19, 2012 (Part 1)

Genetic Aberrations Seen as Path to Stop Colon Cancer

By GINA KOLATA

More than 200 researchers investigating colon cancer tumors have found genetic vulnerabilities that could lead to powerful new treatments. The hope is that drugs designed to strike these weak spots will eventually stop a cancer that is now almost inevitably fatal once it has spread.

The colon cancer study, published on Wednesday in Nature, is the first part of a sweeping effort that is expected to produce a flood of discoveries for a wide range of cancers. The colon cancer findings will soon be followed by studies of lung and breast cancers and, later this year, of acute myeloid leukemia. The effort, the $100-million-a-year Cancer Genome Atlas project, is being financed by two government agencies, the National Cancer Institute and the National Human Genome Research Institute.

http://topics.nytimes.com/top/reference/timestopics/people/k/gina_kolata/index.html

http://health.nytimes.com/health/guides/disease/colon-cancer/overview.html?inline=nyt-classifier

http://health.nytimes.com/health/guides/disease/tumor/overview.html?inline=nyt-classifier

http://health.nytimes.com/health/guides/disease/cancer/overview.html?inline=nyt-classifier

http://topics.nytimes.com/top/reference/timestopics/organizations/n/national_cancer_institute/index.html?inline=nyt-org


A Snapshot of the US Health Care System: July 19, 2012 (Part 2)

After Boy’s Death, Hospital Alters Discharging Procedures

By JIM DWYER

NYU Langone Medical Center announced on Wednesday significant changes in its procedures after the death by septic shock of a 12-year-old boy who was sent home from the center with fever and a rapid heart rate.

Three hours after the boy, Rory Staunton, left the emergency room, a laboratory test showed that his blood had extraordinarily high levels of cells associated with bacterial infections. He subsequently went into shock and experienced organ failure, and died three days later, on April 1. His parents said they were not told about the lab results and were unaware of how seriously ill their son was, having been assured that he was suffering from a typical stomach bug.

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―Critical information gathered by his

family doctor and during his first visit to

NYU Langone was not used, was not at

hand or was not viewed as important

when decisions were made about his

care, records show.‖

http://topics.nytimes.com/top/reference/timestopics/people/d/jim_dwyer/index.html

http://health.nytimes.com/health/guides/disease/septic-shock/overview.html?inline=nyt-classifier

http://www.nytimes.com/2012/07/12/nyregion/in-rory-stauntons-fight-for-his-life-signs-that-went-unheeded.html?pagewanted=all





http://health.nytimes.com/health/guides/symptoms/fever/overview.html?inline=nyt-classifier

http://health.nytimes.com/health/guides/test/pulse/overview.html?inline=nyt-classifier

http://health.nytimes.com/health/guides/test/pulse/overview.html?inline=nyt-classifier

© 2012 UnitedHealth Group. Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 4

“Nobody said anything that

night,” Ms. Staunton said.

“None of you followed up the

next day on that kid, and he’s at

home, dying on the couch?”


The Context: Scientific

Accelerating ease and lower cost of human genome sequencing, SNP genotyping and DNA analysis via microarrays

Explosive growth in correlation analysis in molecular medicine

Increased appreciation of: HTE (heterogeneity of treatment effects) in traditional RCTs and throughout EBM; gene/environment interactions;

Other disciples connecting to molecular medicine: Bioinformatics, Computational Biology, POC Diagnostics, Wireless Medicine

Clinical Applications are emerging, notably in Oncology, Transplant, Pharmacogenomics

Source: NATURE | VOL 487 | 19 JULY 2012


The Increasing Complexity of the Central Dogma of Molecular Biology

Source: Feero WG et al. N Engl J Med 2010;362:2001-2011.


―Healthcare is Riding on a Broken Chassis – Only a comprehensive program can fix it…‖ (March 2001)

SIX AIMS FOR

IMPROVEMENT

1. Safe

2. Effective

3. Patient-Centered

4. Timely

5. Efficient

6. Equitable

EFFECTIVE ORGANIZATIONAL SUPPORT

• Invest in Information Technology

• Coordinate Care

• Redesign Care Processes

• Manage Knowledge and Skills

• Develop Effective Multidisciplinary Teams

• Measure and Improve Performance and Outcomes

TEN RULES TO GUIDE

THE REDESIGN OF CARE

• Continuous Healing Relationships

• Evidence Based Decisions

• Customized Care

• Patient as Source of Control

• Shared Knowledge

• Transparency

• Safety as a System Property

• Cooperation Among Clinicians

• Needs are Anticipated

• Waste is Decreased

The IOM calls for


Variation Across Markets in Episode Costs and Care Quality for Cardiac Catheterization (Diagnostic)

Note: Data includes only physicians designated as providing higher-quality care.

Source: Ellis P, Sandy LG et al Health Aff September

2012 vol. 31 no. 9 2084-2093

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Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group. Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

Le

ve

l o

f F

inan

cia

l R

isk

Degree of Provider Integration and Accountability

Fee-for-service

Primary Care

Incentives

Performance-based

Contracts (PBC)

Bundled/Episode

Payments

Shared Savings

Shared Risk

Capitation + PBCOur modular set of value-based

payment models align with a

provider’s risk readiness.

Accountable Care Platform

Value-based Payment Models

Performance-based Programs

Centers of Excellence

Accountable

Care

Programs


How evidence is used to inform medical policy:

• Definition of a ―Covered Service‖ as a contract term

• Use of a defined, structured review process, with an explicit hierarchy of evidence

• Separate consideration of clinical efficacy and effectiveness (to determine whether the service is eligible for coverage) from costs and cost-effectiveness (to guide approaches to promoting optimal quality and affordability)

• Policy Context: Medical Technology innovation valuable, but also can contribute to high and rising health spending without commensurate clinical benefits (too much ―flat of the curve‖ health care)

• All stakeholders need better data to distinguish between ―high‖ and ―low‖ value services—for both populations and for individuals

• State of the Evidence: Often many unanswered questions

• Variation in the depth, breadth and quality of research needed to inform patients and physicians

• Variation in the quality, clarity and underlying evidence from clinical guidelines and other policy statements


Common, Typical Questions:

• Does it work? How strong is the evidence?

• Is a proposed new treatment safe (relative to other available treatments and the natural history of the disease)?

• What specific populations would benefit ? What specific populations would not?

• How does the procedure, service, drug or device improve health outcomes?

• What are the advantages, harms and alternatives to the proposed treatment?

• What is the clinical evidence of effectiveness and safety of the proposed treatment?

• How does it work in the ―real world‖?

• Which study design will answer safety and effectiveness questions specific to the treatment under review?

• What questions can be addressed through retrospective observational series?

• What questions will prospective multi-site observational series answer?

• How do we consider the strength of the evidence (e.g. GRADE) vs. the strength of the recommendations?


Creating Nuanced Clinical Policies (when the evidence is available!)

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Breast Cancer

Screening

Treatment

Colorectal Cancer

Screening

Treatment

Asthma

Diabetes

Hypertension

Cardiovascular

Disease


Using Sophisticated Data and Analytics to Simplify and Synchronize:

Moving from reactive care to proactive care

Cell Phone

Personal Action Plan

Personalized tools, resources and information

Direct Mail

Holistic Member View

Personalized Portal, PHR,

Messages and Email

Onsite Resources,

Biometric Kiosks, etc.

Interactive Coaches,

Online Communities,

Tools and Trackers


14 14 14

Providing Clinically Nuanced Outreach, Support, and Care Facilitation:

Care Managers proactively identify and prioritize opportunities in four major areas:

Powered by

Right Provider

Right Care

Right

Medication

Right

Lifestyle


Creating the Future by Inventing It:

Need greater ―speed to answer‖ and ―speed to use‖

Speed to answer:

Understand the right questions earlier

Create a ―learning health system‖ where information is gathered, analyzed, disseminated as care is being delivered

Capitalize on the opportunities created by ―Big Data‖—sophisticated analysis of observational data

Increase use of modeling/simulation approaches

Speed to use:

Better dissemination; clinical decision support

Specialty society guidance, performance assessment and feedback

Benefit design and incentives e.g. Value-Based Benefits

Need for new (and large) data sets: phenotypes, functional status, patient-reported outcomes

Also continue to need prospective trials that are ―faster, better, cheaper‖

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We need to work together to promote high-value innovation!

perspectives on heterogeneity in health care€¦ · myeloid leukemia. the effort, the...

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